MEDICARE: TREAVOR D FISHER, DDS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D9340	OR

General Provider Information

NPI Number	:	1962765453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREAVOR D FISHER, DDS, LLC

Provider Business Mailing Address
First Line	:	470 HIGHLAND AVE
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2243
Country	:	US
Telephone Number	:	541-269-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 HIGHLAND AVE
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2243
Country	:	US
Telephone Number	:	541-269-2100
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. TREAVOR D FISHER
Credential	:	DDS
Telephone Number	:	541-554-4734

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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